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Incidence, characteristics and outcome of ICU-acquired candidemia in India

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A systematic epidemiological study on intensive care unit (ICU)-acquired candidemia across India.


A prospective, nationwide, multicentric, observational study was conducted at 27 Indian ICUs. Consecutive patients who acquired candidemia after ICU admission were enrolled during April 2011 through September 2012. Clinical and laboratory variables of these patients were recorded. The present study is an analysis of data specific for adult patients.


Among 1,400 ICU-acquired candidemia cases (overall incidence of 6.51 cases/1,000 ICU admission), 65.2 % were adult. Though the study confirmed the already known risk factors for candidemia, the acquisition occurred early after admission to ICU (median 8 days; interquartile range 4–15 days), even infecting patients with lower APACHE II score at admission (median 17.0; mean ± SD 17.2 ± 5.9; interquartile range 14–20). The important finding of the study was the vast spectrum of agents (31 Candida species) causing candidemia and a high rate of isolation of Candida tropicalis (41.6 %). Azole and multidrug resistance were seen in 11.8 and 1.9 % of isolates. Public sector hospitals reported a significantly higher presence of the relatively resistant C. auris (8.2 vs. 3.9 %; p = 0.008) and C. rugosa (5.6 vs. 1.5 %; p = 0.001). The 30-day crude and attributable mortality rates of candidemia patients were 44.7 and 19.6 %, respectively. Logistic regression analysis revealed significant independent predictors of mortality including admission to public sector hospital, APACHE II score at admission, underlying renal failure, central venous catheterization and steroid therapy.


The study highlighted a high burden of candidemia in Indian ICUs, early onset after ICU admission, higher risk despite less severe physiology score at admission and a vast spectrum of agents causing the disease with predominance of C. tropicalis.

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  1. Meyer E, Geffers C, Gastmeier P et al (2013) No increase in primary nosocomial candidemia in 682 German intensive care units during 2006–2011. Euro Surveill 18(24):20505

    PubMed  Google Scholar 

  2. Gonzalez de Molina FJ, Leon C, Ruiz-Santana S et al (2012) Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis. Crit Care 16(3):R105

    Article  PubMed Central  PubMed  Google Scholar 

  3. Nolla-Salas J, Sitges-Serra A, Leon-Gil C et al (1997) Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study group of fungal infection in the ICU. Intensive Care Med 23(1):23–30

    Article  CAS  PubMed  Google Scholar 

  4. Charles PE, Doise JM, Quenot JP et al (2003) Candidemia in critically ill patients: difference of outcome between medical and surgical patients. Intensive Care Med 29(12):2162–2169

    Article  PubMed  Google Scholar 

  5. Guery BP, Arendrup MC, Auzinger G et al (2009) Management of invasive candidiasis and candidemia in adult non-neutropenic intensive care unit patients: part I. Epidemiology and diagnosis. Intensive Care Med 35(1):55–62

    Article  PubMed  Google Scholar 

  6. Lass-Florl C (2009) The changing face of epidemiology of invasive fungal disease in Europe. Mycoses 52(3):197–205

    Article  PubMed  Google Scholar 

  7. Pfaller MA, Diekema DJ (2007) Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev 20(1):133–163

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  8. Maubon D, Garnaud C, Calandra T et al (2014) Resistance of Candida spp. to antifungal drugs in the ICU: where are we now? Intensive Care Med 40(9):1241–1255

    Article  CAS  PubMed  Google Scholar 

  9. CLSI (2008) Reference method for broth dilution antifungal susceptibility testing of yeasts, approved standard. CLSI document M27-A3, 3rd edn. Clinical and Laboratory Standards Institute (CLSI), Wayne, PA

  10. CLSI (2012) Reference method for broth dilution antifungal susceptibility testing of yeasts, fourth informational supplement. CLSI document M27-S4. Clinical and Laboratory Standards Institute, Wayne, PA

  11. Playford EG, Marriott D, Nguyen Q et al (2008) Candidemia in nonneutropenic critically ill patients: risk factors for non-albicans Candida spp. Crit Care Med 36(7):2034–2039

    Article  PubMed  Google Scholar 

  12. Leroy G, Lambiotte F, Thevenin D et al (2011) Evaluation of Candida score in critically ill patients: a prospective, multicenter, observational, cohort study. Ann Intensive Care 1(1):50

    Article  PubMed Central  PubMed  Google Scholar 

  13. Kett DH, Azoulay E, Echeverria PM et al (2011) Candida bloodstream infections in intensive care units: analysis of the extended prevalence of infection in intensive care unit study. Crit Care Med 39(4):665–670

    Article  PubMed  Google Scholar 

  14. Bassetti M, Merelli M, Righi E et al (2013) Epidemiology, species distribution, antifungal susceptibility, and outcome of candidemia across five sites in Italy and Spain. J Clin Microbiol 51(12):4167–4172

    Article  PubMed Central  PubMed  Google Scholar 

  15. Chow JK, Golan Y, Ruthazer R et al (2008) Risk factors for albicans and non-albicans candidemia in the intensive care unit. Crit Care Med 36(7):1993–1998

    Article  PubMed  Google Scholar 

  16. Leroy O, Gangneux JP, Montravers P et al (2009) Epidemiology, management, and risk factors for death of invasive Candida infections in critical care: a multicenter, prospective, observational study in France (2005–2006). Crit Care Med 37(5):1612–1618

    Article  PubMed  Google Scholar 

  17. Pappas PG, Rex JH, Lee J et al (2003) A prospective observational study of candidemia: epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis 37(5):634–643

    Article  PubMed  Google Scholar 

  18. Chen S, Slavin M, Nguyen Q et al (2006) Active surveillance for candidemia, Australia. Emerg Infect Dis 12(10):1508–1516

    Article  PubMed Central  PubMed  Google Scholar 

  19. Leroy O, Mira JP, Montravers P et al (2010) Comparison of albicans vs. non-albicans candidemia in French intensive care units. Crit Care 14(3):R98

    Article  PubMed Central  PubMed  Google Scholar 

  20. Pfaller MA, Messer SA, Moet GJ et al (2011) Candida bloodstream infections: comparison of species distribution and resistance to echinocandin and azole antifungal agents in intensive care unit (ICU) and non-ICU settings in the SENTRY antimicrobial surveillance program (2008–2009). Int J Antimicrob Agents 38(1):65–69

    Article  CAS  PubMed  Google Scholar 

  21. White MH (1997) The contribution of fluconazole to the changing epidemiology of invasive candidal infections. Clin Infect Dis 24(6):1129–1130

    Article  CAS  PubMed  Google Scholar 

  22. Lortholary O, Renaudat C, Sitbon K et al (2014) Worrisome trends in incidence and mortality of candidemia in intensive care units (Paris area, 2002–2010). Intensive Care Med 40(9):1303–1312

    Article  PubMed Central  PubMed  Google Scholar 

  23. Chakrabarti A, Chatterjee SS, Rao KL et al (2009) Recent experience with fungaemia: change in species distribution and azole resistance. Scand J Infect Dis 41(4):275–284

    Article  CAS  PubMed  Google Scholar 

  24. Mootsikapun P, Hsueh PR, Talwar D et al (2013) Intravenous anidulafungin followed optionally by oral voriconazole for the treatment of candidemia in Asian patients: results from an open-label phase III trial. BMC Infect Dis 13:219

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  25. Fournier P, Schwebel C, Maubon D et al (2011) Antifungal use influences Candida species distribution and susceptibility in the intensive care unit. J Antimicrob Chemother 66(12):2880–2886

    Article  CAS  PubMed  Google Scholar 

  26. Blot S, Janssens R, Claeys G et al (2006) Effect of fluconazole consumption on long-term trends in candidal ecology. J Antimicrob Chemother 58(2):474–477

    Article  CAS  PubMed  Google Scholar 

  27. Lockhart SR, Messer SA, Gherna M et al (2009) Identification of Candida nivariensis and Candida bracarensis in a large global collection of Candida glabrata isolates: comparison to the literature. J Clin Microbiol 47(4):1216–1217

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  28. Leon C, Ostrosky-Zeichner L, Schuster M (2014) What’s new in the clinical and diagnostic management of invasive candidiasis in critically ill patients. Intensive Care Med 40(6):808–819

    Article  CAS  PubMed  Google Scholar 

  29. Blot SI, Vandewoude KH, Hoste EA et al (2002) Effects of nosocomial candidemia on outcomes of critically ill patients. Am J Med 113(6):480–485

    Article  PubMed  Google Scholar 

  30. Nucci M, Anaissie E, Betts RF et al (2010) Early removal of central venous catheter in patients with candidemia does not improve outcome: analysis of 842 patients from 2 randomized clinical trials. Clin Infect Dis 51(3):295–303

    Article  PubMed  Google Scholar 

  31. Gudlaugsson O, Gillespie S, Lee K et al (2003) Attributable mortality of nosocomial candidemia, revisited. Clin Infect Dis 37(9):1172–1177

    Article  PubMed  Google Scholar 

  32. Das I, Nightingale P, Patel M et al (2011) Epidemiology, clinical characteristics, and outcome of candidemia: experience in a tertiary referral center in the UK. Int J Infect Dis 15(11):e759–e763

    Article  CAS  PubMed  Google Scholar 

  33. Colombo AL, Guimaraes T, Sukienik T et al (2014) Prognostic factors and historical trends in the epidemiology of candidemia in critically ill patients: an analysis of five multicenter studies sequentially conducted over a 9-year period. Intensive Care Med 40(10):1489–1498

    Article  PubMed Central  PubMed  Google Scholar 

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We wish to acknowledge Prof. Niranjan Nayak, President SIHAM for providing us invaluable logistic support and continuous encouragement to accomplish this study. Other members of the SIHAM Candidemia Network include (participating centres in parenthesis; in alphabetical order): Purva Mathur (All India Institute of Medical Sciences, New Delhi, India); Ratnamani (Apollo Hospital, Hyderabad, India); Aroma Oberoi, Ashu Sara Mathai (Christian Medical College and Hospital, Ludhiana, India); Shweta Sharma (Fortis Escorts Heart Institute, New Delhi, India); DC Thamke (Mahatma Gandhi Institute of Medical Sciences, Wardha, India); A Krishna Prasad (Nizam’s Institute of Medical Sciences, Hyderabad, India); Camilla Rodrigues, Mahesh Lakhe, Mehul Panchal, Niyati Desai (PD Hinduja, Mumbai, India); Gagandeep Singh, Ashutosh Nath Aggarwal, Neerja Bhardwaj, L N Yaddanapudi, Joseph Jillwin, A Shamnath (Postgraduate Institute of Medical Education and Research, Chandigarh); Pradeep Kumar Verma, Harish Chand Sachdeva (Safdarjang Hospital, New Delhi, India); Sriram Sampath (St John’s Medical College, Bangalore, India) are also acknowledged for their help. This work was supported by the MSD Pharmaceuticals Pvt. Ltd Educational Grant through the Society for Indian Human and Animal Mycologists, an affiliate of the International Society of Human and Animal Mycology. MSD did not play any role in study design, data analysis or manuscript writing.

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The authors declare that they have no conflicts of interest and no financial relationship with the funding agency.

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Correspondence to Arunaloke Chakrabarti.

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For the SIHAM Candidemia Network.

Take home message: This multicentric study from India on ICU-acquired candidemia highlights the unique epidemiology of this country with its vast spectrum of Candida species and high rate of C. tropicalis isolation. The disease occurred comparatively early after ICU admission, even in patients with less severe physiology scores.

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Chakrabarti, A., Sood, P., Rudramurthy, S.M. et al. Incidence, characteristics and outcome of ICU-acquired candidemia in India. Intensive Care Med 41, 285–295 (2015).

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